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756 asia pac j clin nutr 2018 27 4 756 762 original article development of a screening tool to detect nutrition risk in patients with inflammatory bowel disease 1 1 ...

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               756                                                                                                                         Asia Pac J Clin Nutr 2018;27(4):756-762   
               Original Article 
                
               Development of a screening tool to detect nutrition risk 
               in patients with inflammatory bowel disease  
                
                                                    1                                                                 1,2
               Natasha Haskey RD, MSc , Juan Nicolás Peña-Sánchez MD, MPH, PhD ,  
                                                     3                                   1
               Jennifer L Jones MD, MSc , Sharyle A Fowler MD  
                
               1
                Multidisciplinary Inflammatory Bowel Disease Clinic, Division of Gastroenterology, Department of  
               Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada 
               2
                Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, 
               Canada 
               3
                Division of Digestive Care & Endoscopy, Department of Medicine, Dalhousie University, Halifax, Nova  
               Scotia, Canada 
                
                                                                                   
                         Background and Objectives: Malnutrition is a known complication of Inflammatory Bowel Disease (IBD). We 
                         assessed a known screening tool, as well as developed and validated a novel screening tool, to detect nutrition 
                         risk in outpatients with IBD. Methods and Study Design: The Saskatchewan IBD–Nutrition Risk (SaskIBD-NR 
                         Tool) was developed and administered alongside the Malnutrition Universal Screening Tool (MUST). Nutrition 
                         risk was confirmed by the IBD dietitian (RD) and gastroenterologist (GI). Agreement between screening tools 
                         and RD/GI assessment was computed using Cohen’s kappa. Results: Of the 110 patients screened, 75 (68.2%) 
                                                                                                                   2
                         patients had Crohn’s Disease and 35 (31.8%) ulcerative colitis. Mean BMI was 26.4 kg/m  (SD=5.8). RD/GI as-
                         sessment identified 23 patients (20.9%) at nutrition risk. The SaskIBD-NR tool classified 21 (19.1%) at some nu-
                         trition risk, while MUST classified 17 (15.5%). The SaskIBD-NR tool had significant agreement with the RD/GI 
                         assessment (k 0.83, p<0.001), while MUST showed a lack of agreement (k 0.15, p=0.12). The SaskIBD-NR had 
                         better sensitivity (82.6% vs 26.1%), specificity (97.7% vs 87.4%), positive predictive value (90.5% vs 35.3%), 
                         and negative predictive value (95.5% vs 81.7%) than the MUST. Conclusion: The SaskIBD-NR, which assesses 
                         GI symptoms, food restriction, and weight loss, adequately detects nutrition risk in IBD patients. Broader valida-
                         tion is required. 
                                                                                          
               Key Words: nutrition screening tool, nutrition risk, inflammatory bowel disease, Crohn’s disease, ulcerative colitis 
                
                                                                                                                     
                                                                                                                     
               INTRODUCTION                                                         and undertreatment of both malnutrition and nutrient de-
                                                                                               1,14
               Malnutrition and weight loss are well recognized compli-             ficiencies.    The Subjective Global Assessment (SGA) is 
                                                                  1 
               cations of inflammatory bowel disease (IBD). One of the              widely considered the gold standard to diagnose patients 
                                                                                                                                       15
               most  under  recognized  mechanisms  of  malnutrition  is            who are moderately or severely malnourished.  However, 
               reduced  food  intake  and  specific  avoidance  of  foods            patients who are at risk of malnutrition should be identi-
               among IBD patients. Up to 90% of Crohn’s disease (CD)                fied early when interventions can be applied, rather than 
               patients  and  71%  of  ulcerative  colitis  (UC)  patients  in      once they are already malnourished. SGA does not assess 
                                                                              2
               remission  use  elimination  diets  to  control  symptoms.           whether patients are avoiding food items or food groups. 
               Protein-energy malnutrition is common in active, severe              A screening tool to detect IBD patients at risk of malnu-
               IBD; however micronutrient deficiencies (vitamins, min-              trition and nutrient deficiencies, rather than those who are 
               erals and trace elements) are seen even in patients with             already malnourished, is therefore needed. Existing nutri-
               mild disease or in clinical remission. Micronutrient defi-           tion screening tools may be of limited use in the IBD out-
               ciencies  can  lead  to  co-morbidities  including  anemia,          patient population, as BMI and weight loss are often key 
               osteoporosis, thrombophilia, colorectal cancer, and poor 
                                                                                     
                                3
               wound healing.  Weight loss may not be the best measure 
                                                                                    Corresponding  Author:  Natasha  Haskey,  Multidisciplinary 
               of nutrition risk in IBD, as emerging literature suggests 
                                                                                    Inflammatory Bowel Disease Clinic, Division of Gastroenterol-
               that  IBD  patients  in  remission  have  similar  body  mass 
                                                                                    ogy,  Department  of  Medicine,  University  of  Saskatchewan, 
                                                      4,5
               indices (BMI) as healthy controls.  As well, there is a 
                                                                                    Royal University Hospital, 103 Hospital Drive, Saskatoon, Sas-
                                                                          6-10
               growing prevalence of obesity in the IBD population.           
                                                                                    katchewan, Canada S7N 0W8.  
                  A number of nutrition screening tools are available that 
                                                                                    Tel: +001-306-290-7350; Fax: +001-306-844-1523 
               have been validated in a variety of populations including 
                                                                                    Email: natasha.haskey@gmail.com; nhaskey@shaw.ca 
                                                               11-13 
               medical, oncologic, and surgical patients.           However, 
                                                                                    Manuscript received 24 December 2016. Initial review complet-
               routine nutrition screening is not commonly performed in             ed 15 February 2017. Revision accepted 10 April 2017.  
               the IBD outpatient setting, resulting in under detection             doi: 10.6133/apjcn.112017.01 
                                                                               Nutrition screening for inflammatory bowel disease                                             757 
                                                                                                                                                                   1,3-7                           19
                      measures used in these tools. A recent systematic review                                            oped from the literature,                       available tools,  and clini-
                      indicates that BMI does not accurately predict body com-                                            cian experience. The SaskIBD-NR Tool considers symp-
                                                16
                      position in IBD  and the growing prevalence of obesity                                              toms  (nausea,  vomiting,  and  diarrhea),  nutrient  intake 
                                                            6-10
                      in the IBD population,                       means that patients with nor-                          (food  intake  and  food  avoidance),  and  unintentional 
                      mal or elevated BMIs may not be appropriately identified                                            weight loss, all of which are all well-defined risk factors 
                      as at risk of malnutrition with traditional screening tools.                                        for malnutrition in the IBD outpatient population. Ques-
                                                                                                                12
                          The  malnutrition  universal  screening  tool  (MUST)                                           tions pertaining to symptoms gauge IBD disease activity 
                      has been validated in varied populations, including medi-                                           (active  or  remission).  Questions  pertaining  to  nutrient 
                                                                                                         17
                      cal, surgical, and general gastroenterology patients.  The                                          intake  screen  for  potential  micronutrient  deficiency. 
                      tool focuses on BMI, weight loss, and the acute disease                                             Questions relating to weight loss screen for potential pro-
                      effect. Although the MUST has not been validated specif-                                            tein-energy  malnutrition.  Once  a  final  version  of  the 
                      ically in the IBD patient population, it has been reported                                          questionnaire  was  defined,  content  validity  of  the  tool 
                      to be quick and easy to use which is desirable in demand-                                           was  evaluated  by  the  Saskatchewan  multidisciplinary 
                                                                       17,18
                      ing  IBD  outpatient  settings.                          A  recent  publication                     IBD team which acted as a committee of experts. Subse-
                      showed that patient-administered MUST was comparable                                                quently,  the  SaskIBD-NR  Tool  was  piloted  by  dietetic 
                      to  healthcare  practitioner-administered  MUST,  in  the                                           interns with five IBD patients to determine if the ques-
                                                                     18
                      outpatient IBD clinic setting.  However, potential limita-                                          tions were clear and easy to understand.  
                      tions of MUST are the emphasis it places on BMI, and                                                     
                      that  it  does  not  take  into  consideration  recent  nutrient                                    Sample 
                      intake and food avoidance, which are risk factors for mi-                                           The study was conducted in the outpatient department at 
                      cronutrient deficiencies.                                                                           Royal University Hospital in Saskatoon, Saskatchewan, 
                           A screening tool to detect nutrition risk that is quick                                        Canada  in  the  Multidisciplinary  Inflammatory  Bowel 
                      and easy to administer and that identifies key nutrition                                            Disease Clinic over a three-month period. A convenience 
                      risk  factors  in  the  IBD  outpatient  population  does  not                                      sample of 110 outpatients with IBD participated in the 
                      currently exist in clinical practice. Given that elimination                                        study. All participants in the study were ≥18 years, and 
                      diets,  food  exclusion and micronutrient deficiencies are                                          had an established diagnosis of IBD based on standard 
                      common in IBD patients, and that BMI may not be an                                                  clinical,  radiologic,  endoscopic  and  histologic  criteria. 
                      accurate predictor of nutrition risk in this population, the                                        Pregnant women with IBD were excluded.  
                      aim of this study was to develop a reliable and valid nu-                                               Prior  to  entering  the  treatment  room,  weight  (kilo-
                      trition  screening  tool  that  would  identify  patients  with                                     grams) and height (meters) were completed by support 
                      IBD at risk for malnutrition and potential nutrient defi-                                           staff, and BMI was calculated (kilograms divided by me-
                      ciencies in the outpatient setting.                                                                 ters  squared).  Patients  were asked the  questions  on the 
                                                                                                                          SaskIBD-NR Tool (Table 1) and the MUST (Table 2) by 
                      MATERIALS AND METHODS                                                                               the  gastroenterologist,  dietitian,  or  nurse  practitioner  as 
                      Development of a nutrition screening tool for patients                                              part  of  the  patient’s  regularly  scheduled  appointment.  
                      with IBD                                                                                            Responses to each of the nutrition screening questions in 
                      The Saskatchewan Inflammatory Bowel Disease – Nutri-                                                the  SaskIBD-NR  Tool  and  MUST  were  given  a  score 
                      tion Risk Tool (SaskIBD-NR Tool) is a locally developed                                             (low, medium or high-risk categories). For the purposes 
                      screening tool that was initially developed by three die-                                           of  analysis,  patients  falling  into  the  ‘at  risk’/‘medium 
                      tetic interns. Key criteria for development of the nutrition                                        risk’  and  ‘malnourished’/‘high  risk’  groups  (≥1  for 
                      screening tool were that it 1) be simple, quick and easily                                          MUST and ≥3 for the SaskIBD-NR Tool) were combined 
                      completed  by  all  team  members;  2)  use  data  that  was                                        into one ‘pooled-risk’ group for each method of screen-
                      routinely available; 3) be non-invasive and economical; 4)                                          ing. This method of combining risk groups has been pre-
                                                                                                                                                                              17,19-21 
                      could be incorporated into routine assessment; and 5) be                                            viously used in similar studies.                               The prevalence of 
                      valid and reliable. The dietetic interns met with the mul-                                          nutrition risk using both screening tools was compared. 
                      tidisciplinary IBD team (Registered Dietitian, two Gas-                                                
                      troenterologists, Nurse Practitioner, Nurse Clinician, and                                          Reliability of the SaskIBD-NR and the MUST screening 
                      IBD  Research  Coordinator)  to  determine  nutrition  risk                                         tools 
                      factors  that  should  be  incorporated  into  a  nutrition                                         The Registered Dietitian and Gastroenterologist (RD/GI) 
                      screening tool.                                                                                     assessment was chosen as the “gold standard” for deter-
                          The  questions  in  the  SaskIBD-NR  Tool  were  devel-                                         mining the actual risk of malnutrition. A major challenge 
                          
                         Table 1. SaskIBD-NR Tool 
                          
                         Nutrition screening item                                                                                Score 
                         1. Have you experienced nausea, vomiting, diarrhea or poor appetite                                     “no symptoms”=0, “1-2 symptoms”=1, “≥3 symptoms”=2 
                                  for greater than two weeks? 
                         2. Have you lost weight in the last month without trying?                                               “no”=0, “unsure”=1, “yes”=see below 
                                                                                                                                  
                         IF YES, how much weight have you lost?                                                                  “<5 lbs”=0, “5-10 lbs”=1, “10-15 lbs”=2, “>15 lbs”=3 
                         3. Have you been eating poorly because of a decreased appetite?                                         “no”=0, “yes”=2 
                         4. Have you been restricting any foods or food groups?                                                  “no”=0, “yes”=2 
                          
                         Total score: 0-2=low risk, 3-4=medium risk, ≥5=high risk. 
                          
                 758                                       N Haskey, JN Peña-Sánchez, JL Jones and SA Fowler 
                   Table 2. MUST 
                    
                   Nutrition screening item                                                      Score 
                   Step 1: BMI score                                                             “>20”= 0, “18.5-20”= 1, “<18.5”= 2 
                                       2
                           BMI=kg/m                                                               
                   Step 2: Weight loss score                                                     “<5”= 0, “5-10”= 1, “>10”= 2 
                           Unplanned weight loss in past 3-6 months (% Score)                     
                   Step 3: Acute disease effect score                                            “no”= 0, “yes”=2 
                            Patient is acutely ill and there has been or is likely to be no       
                            nutritional intake for >5 days 
                    
                   Total score: 0=low risk, 1=medium risk, ≥2=high risk 
                    
                    
                   Table 3. Criteria used to determine nutrition risk: RD/GI assessment 
                    
                     Diagnosis (Crohn’s disease or ulcerative colitis) 
                     Body mass index (BMI) 
                     Unintentional weight loss 
                     Presence or absence of symptoms (stools, vomiting, nausea, pain) 
                     Location of disease, disease severity, concurrent conditions 
                     Surgical history 
                     Medications 
                     Laboratory parameters (albumin, vitamin D, iron status, vitamin B12) 
                                                               †                                   †
                     Simple Colitis Activity Index (SCAI) , Harvey Bradshaw score (HBS)  
                     Intake (appetite, food restriction) 
                    
                   †
                    When available. 
                    
                 to validating nutrition risk screening tools is the absence                MUST  and  SaskIBD-NR  screening  tools.    Using  the 
                 of single “gold standard” for identifying patients at risk                 pooled-risk groups, sensitivity, specificity, positive pre-
                                    22 
                 of malnutrition.     The SGA is widely considered the gold                 dicted value (PPV), negative predictive value (NPV), and 
                 standard  in  many  studies  pertaining  to  malnutrition.                 ROC area were computed, with their respective 95% con-
                 However,  the  SGA  identifies  patients  who  are  already                fidence  intervals  (95%  CI),  for  the  SaskIBD-NR  and 
                 moderately  or  severely  malnourished, rather  than those                 MUST  screening  tools.  Inter-rater  reliability  was  not 
                 who are at risk of becoming malnourished. SGA exam-                        evaluated given that each evaluation was completed by a 
                 ines overall nutrition intake versus specific food avoid-                  gastroenterologist, dietitian, or nurse practitioner. Statis-
                                                                            2,23,24
                 ance which is common in the IBD population.                        As      tical analyses were performed using IBM SPSS Statistics 
                 well, a study assessing different indicators of malnutri-                  version 23 (SPSS Inc. Chicago, IL) and the diagti com-
                 tion in IBD patients found that although 74% of patients                   mand in STATA version 13 (Stata Corporation, College 
                 were well nourished according to the SGA, these patients                   Station, TX). 
                 had decreases in body cell mass and handgrip strength                         The University of Saskatchewan Research Ethics pro-
                                           5
                 compared to controls.  We therefore instead used a com-                    vided an exemption for ethics board review prior to ini-
                 prehensive assessment by the RD/GI as the “gold stand-                     tiation of the study. Patients provided informed consent 
                 ard” for determining the patients who are at risk of mal-                  for the use of their data in the evaluation of these screen-
                 nutrition.                                                                 ing tools. If patients were deemed at nutrition risk, by any 
                    For each patient, the RD and GI completed a retrospec-                  method, they were referred to the RD for further assess-
                 tive chart review using the criteria outlined in Table 3 to                ment. 
                 determine nutrition risk. No formal scores were assigned                       
                 for each criterion.  Rather, all the factors were taken into               RESULTS 
                 account by the RD and GI to determine if patients were                     The SaskIBD-NR Tool 
                 either ‘not at risk’ or ‘at risk’ of malnutrition. The RD/GI               The SaskIBD-NR Tool evaluates four components: gas-
                 assessment was completed within one week of the nutri-                     trointestinal symptoms, weight loss, anorexia, and food 
                 tion  screening. The  RD  and  GI  were  not aware  of  the                restrictions (Table 1). This nutrition screening tool was 
                 scores of the SaskIBD-NR or the MUST until the chart                       specifically developed for patients with IBD. The com-
                 review (RD/GI assessment) was completed. Upon com-                         mittee of experts verified the content validity of the final 
                 pletion  of  the  chart  review  the  patient’s  scores  on  the           version of the SaskIBD-NR Tool and approved it. In the 
                 SaskIBD-NR Tool and the MUST were compared to the                          pilot, patients with IBD confirmed that the questions of 
                 RD/GI  assessment.  To  assess  concurrent  validity,  the                 the screening tool were clear and understandable.  
                 SaskIBD-NR Tool and the MUST score were compared.                              
                    Cohen’s  kappa  statistic  was  computed  to  measure                   Sample group 
                 agreement  between  the  SaskIBD-NR  tool  and  RD/GI                      Demographics and clinical characteristics of IBD patients 
                 assessment, as  well  as  between  MUST  and  RD/GI  as-                   are  summarized  in  Table  4.  Mean  age  was  39  years 
                 sessment.    Receiver  operating  characteristic  (ROC)                    (SD=15),  63  (57.3%)  participants  were  female,  75 
                 curves  were  also  drawn  using  the  actual  scores  of  the             (68.2%) patients had CD, and 35 (31.8%) UC. Mean BMI 
                                                              Nutrition screening for inflammatory bowel disease                                             759 
                                    2
                 Was 26.4 kg/m  (SD=5.8).  
                                                                                                 Table  4.  Demographics  and  clinical  characteristics 
                    
                                                                                                 (n=110) 
                 Reliability of the SaskIBD-NR and the MUST screening                             
                                                                                                                                          Mean±SD, range/n (%)  
                 tools 
                                                                                                                    
                                                                                                 Age, years                                  39±15, 17-79 
                 All  participants  were  screened  with  the  SaskIBD-NR 
                                                                                                 Gender                                          
                 Tool, MUST and had a RD/GI nutrition risk assessment. 
                                                                                                  Female                                     63 (57.3) 
                 Differences were observed in the prevalence of IBD pa-
                                                                                                                           2
                                                                                                 Body mass index (kg/m )                     26.4±5.8, 17.7-43.2 
                 tients at nutritional risk using these 3 methods of assess-                                †
                                                                                                 Diagnosis                                       
                 ment (Figure 1). The RD/GI assessment identified 20.9% 
                                                                                                  CD                                         75 (68.2) 
                 (95% CI 13.7-29.7%, n=23) of the patients at nutritional                           Upper gastrointestinal                     2 (2.7) 
                                                                                                    Ileal                                    21 (28) 
                 risk.  The  SaskIBD-NR Tool classified 19.1% (95% CI 
                                                                                                    Colonic                                  21 (28) 
                 12.2-27.7%, n=21) of the patients at some nutritional risk: 
                                                                                                    Ileocolonic                              32 (42.7) 
                 9 (8.2%, 95% CI 3.8-15%) at high risk and 12 (10.9%, 
                                                                                                    Perianal                                 11 (14.7) 
                 95%CI  5.8-18.3%)  at  medium  risk.  In  contrast,  the 
                                                                                                  UC                                         35 (31.8) 
                 MUST considered that only 15.5% (95%CI 9.3-23.6%, 
                                                                                                    Proctitis                                  7 (20) 
                 n=17)  of  the  patients  were  at  some  nutritional  risk:  5                    Left-sided colitis                       16 (45.7) 
                                                                                                    Extensive colitis                        12 (34.3) 
                 (4.5%, 95%CI 1.5-10.3%) at high risk and 12 (10.9%, 
                                                                                                            ‡
                                                                                                 HBI score                                     4.2±6.7, 0-35 
                 95%CI 5.8-18.3%) at medium risk.  
                                                                                                               §
                                                                                                 SCCAI score                                   1.3±2.2, 0-9 
                     The  results  of  the  nutritional  screening  tools  were 
                                                                                                 Medication type for IBD (%)                     
                 compared with the results of the RD/GI assessment (Ta-
                                                                                                  None                                       16 (14.5) 
                 ble 5). A high and significant agreement was identified 
                                                                                                  5-aminosalicylic acid                      32 (29.1) 
                 between  the  SaskIBD-NR  Tool  and  RD/GI assessment                            Corticosteroids                              5 (4.5) 
                                                                                                  Immunomodulator monotherapy                17 (15.5) 
                 (kappa  0.83,  p<0.001),  with  good  levels  of  agreement 
                                                                                                  Anti-TNF monotherapy                       14 (12.7) 
                 among both patients with CD (kappa 0.82, p<0.001) and 
                                                                                                  Other biologics                              3 (2.7) 
                 UC (kappa 0.84, p<0.001). Conversely, a lack of agree-
                                                                                                  Immunomodulator + biologic                 13 (11.8) 
                 ment was observed between the MUST and RD/GI as-
                                                                                                  Other combined schemes                     10 (9.1) 
                                                                                                  
                 sessment  (kappa  0.15,  p=0.12).  This  disagreement  was 
                                                                                                 †
                                                                                                 Percentages total more than 100% because some patients have 
                 similar among patients with CD (kappa 0.14, p=0.27) and 
                                                                                                 been counted in more than one category. 
                 UC  (kappa  0.16,  p=0.31).  There  was  no  significant 
                                                                                                 ‡
                                                                                                 Harvey-Bradshaw Index (HBI), n=67. 
                 agreement  between  the  SaskIBD-NR  Tool  and  MUST                            §
                                                                                                 Simple Clinical Colitis Activity Index (SCCAI), n=33. 
                 (kappa: 0.18, p=0.06). A larger ROC area was observed 
                                                                                                  
                 for the SaskIBD-NR tool (97.7%, 95% CI 95.5-98.3%) in 
                                                                                                  Sensitivity  and  specificity  of  the  SaskIBD-NR  Tool 
                 comparison to the ROC area of the MUST (56.4%, 95% 
                                                                                               was tested at different cut-off values to determine varia-
                 CI 46.7-66%) (Figure  2a).Using  the  pooled-risk  group, 
                                                                                               tions of this screening tool. This evaluation identified that 
                 the  ROC  area  of  the  SaskIBD-NR  Tool  was  90.2% 
                                                                                               the chosen cut-off in this study (i.e., classifying IBD pa-
                 (95%CI 82.1-98.2%) versus 56.7% (95% CI 46.9-66.5%) 
                                                                                               tients  with a score of ≥3 as at risk of malnutrition and 
                 for the MUST (Figure 2b).  
                                                                                               those with a score of <2 at low risk of malnutrition) had 
                    
                                                                                                                                                               
                                                                                             
                   Figure 1. Prevalence of IBD patients at nutritional risk according to the RD/GI nutrition risk assessment, SaskIBD-NR Tool, and MUST. 
                    
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...Asia pac j clin nutr original article development of a screening tool to detect nutrition risk in patients with inflammatory bowel disease natasha haskey rd msc juan nicolas pena sanchez md mph phd jennifer l jones sharyle fowler multidisciplinary clinic division gastroenterology department medicine university saskatchewan saskatoon canada community health and epidemiology digestive care endoscopy dalhousie halifax nova scotia background objectives malnutrition is known complication ibd we assessed as well developed validated novel outpatients methods study design the saskibd nr was administered alongside universal must confirmed by dietitian gastroenterologist gi agreement between tools assessment computed using cohen s kappa results screened had crohn ulcerative colitis mean bmi kg m sd sessment identified at classified some nu trition while significant k p days total score low medium high table criteria used determine diagnosis or body mass index unintentional weight loss presence a...

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